Male urinary incontinence and the urinary sheath Abstract
This article addresses the assessment and management of male incontinence with a specific focus on the use of the male external catheter (MEC) or urinary sheath. Education and expertise when dealing with a man with urinary incontinence, as well as a tactful and sensitive attitude towards this embarrassing problem, are essential for a successful outcome. The urinary sheath is often perceived by nurses and patients as a difficult product to master and is prone to failure owing to incorrect fitting and management. With correct usage it can make a great difference to a patient’s quality of life and avoid problems often associated with urinary catheters and pads such as urinary infection and skin excoriation. Detailed assessment of the patient as well as his suitability for the MEC is essential for a successful outcome. Key words: Male urinary incontinence ■ Male external catheter
■
Urinary sheath
M
ale urinary incontinence remains a taboo subject and because of this many men may be reluctant to seek help with what is often a distressing problem. Urinary incontinence has been defined by the International Continence Society (ICS) as ‘the complaint of any involuntary leakage of urine’ (Sand and Dmouchowski, 2002). In the UK it is estimated that between 2.5 and 4 million adults have continence problems (Continence Foundation, 2000). Of these, one in 33 men living at home aged 15–64 is incontinent of urine and this increases to between one in 14 and one in 10 men aged 65 and over (Department of Health, 2000). Given the increasing ageing population this figure will be a lot higher today and the impact on the individual person’s physical and psychological health cannot be underestimated. Nurses in primary or secondary care are in a prime position to offer assessment and treatment for male incontinence and men may be more willing to admit to having this problem with a nurse who they see regularly as part of ongoing management of chronic health problems than an unfamiliar hospital specialist.
Clare Smart is Urology Nurse Specialist in Benign Urology, Homerton University Hospital, London Accepted for publication: April 2014
S20
The National Institute for Health and Care Excellence (NICE), in its guidelines for the management of lower urinary tract symptoms in men, state that in men with storage symptoms, especially urinary incontinence, a choice of containment products should be offered based on the individual’s circumstances and in consultation with the man (NICE, 2010). This would include external collecting devices, and the urinary sheath is a good example. There is, however, a prevailing negative attitude to using urinary sheaths among nurses as they are not easy to use without appropriate training and knowledge. Once a system has failed because of poor initial assessment, poor fitting, and inappropriate product choice (Booth and Lee, 2005) it is hard to convince a client or health professional that it can be an effective device and that it compares favourably with other methods of urinary containment. This article addresses the assessment and management of male urinary incontinence with a focus on the urinary sheath as a good method of treating incontinence while improving the man’s quality of life. At this point it would be useful to categorise the clinical subtypes of urinary incontinence that can be experienced by men. The following definitions are described by the ICS: ■■ Stress incontinence: involuntary leakage on effort or exertion, sneezing or coughing ■■ Urge incontinence: involuntary leakage of urine accompanied or immediately preceded by urgency (a compelling desire to void that is difficult to defer) ■■ Mixed incontinence: involves components of both stressrelated and urgency-related leakage ■■ Enuresis: any involuntary loss of urine ■■ Nocturnal enuresis: involuntary loss of urine during sleep ■■ Continuous urinary incontinence: continuous leakage. Men may also experience the following conditions, which can lead to incontinence of urine: ■■ Chronic retention of urine: a non-painful bladder, which remains palpable or percussable after the patient has passed urine ■■ Feeling of incomplete emptying: a self-explanatory term for a feeling experienced by the individual after passing urine ■■ Post-micturition dribble: the involuntary loss of urine immediately after the person has finished passing urine, usually after leaving the toilet ■■ Detrusor overactivity (overactive bladder) is a urodynamic observation characterised by involuntary detrusor contractions during the filling phase of the test, which may be spontaneous or provoked (Abrams et al, 2002).
© 2014 MA Healthcare Ltd
Clare Smart
British Journal of Nursing, 2014 (Urology Supplement), Vol 23, No 9
British Journal of Nursing. Downloaded from magonlinelibrary.com by 155.198.030.043 on December 3, 2015. For personal use only. No other uses without permission. . All rights reserved.
Any urinary incontinence should first be investigated as part of a full assessment of the problem. A holistic and sympathetic approach by the health professional is vital to elicit as much information from the patient as possible so that management can be tailored to the individual’s needs. A detailed history and examination will form the basis of investigation into the cause of the incontinence and an assessment of the impact it is having on the individual will guide the type of management that is most suitable. Two useful tools when assessing male lower urinary tract symptoms are the International Prostate Symptom Score (IPSS) and the frequency/volume chart (Busuttil-Leaver, 2009) These help to quantify and categorise the symptoms so that a tentative diagnosis can be made. In addition to these, a detailed medical, surgical, family and medication history should be taken and an evaluation of the social context of the individual and the degree of bother the problem is causing him. Special note should be taken of conditions that often give rise to incontinence such as Parkinson’s disease, cerebrovascular accident, benign prostatic hyperplasia, diabetes, multiple sclerosis, spinal cord injury or disease, urinary tract carcinoma, radiotherapy to pelvic region, surgery to the spine or urological tract (Crestodina, 2007). If the nurse is competent in examining the patient, a focused physical examination should include abdominal examination to detect a palpable bladder (which indicates bladder outflow obstruction), a digital rectal examination of the prostate and rectum (to detect enlarged or diseased prostate, faecal impaction or rectal mass), examination of the genitalia and skin condition (retracted penis, phimosis, excoriation), pelvic floor assessment and a test for leakage of urine on coughing (indicating stress incontinence), and neurological examination. First-line investigations should include urinalysis (to exclude UTI, diabetes and haematuria) and a frequency/ volume chart that has been completed by the patient for at least 3 days at home and at work. If a bladder scanner and a flow rate machine is available, a flow rate and a post-void scan is useful to determine whether or not the patient has an obstructed flow and is retaining urine. Red flag conditions that must be excluded include bladder carcinoma (indicated by haematuria) and chronic retention with overflow (indicated by a palpable bladder) (Mangera and Chapple, 2010).
Differential diagnosis As well as identifying the various types of urinary incontinence already described it is important to recognise transient incontinence which can be correctable. A useful acronym, DIAPPERS can help to identify the cause and stands for: ■■ Delirium ■■ Infection and/or bladder irritants ■■ Atrophic vaginitis/urethritis ■■ Pharmacological causes ■■ Psychological causes ■■ Excessive urine production ■■ Restricted mobility
S22
■■ Stool
impaction. Once a cause has been identified and corrected the patient’s symptoms may improve (Crestodina, 2007).
Management of urinary incontinence The management of incontinence depends on identifying the correct cause of the problem and putting into place treatment and/or lifestyle measures that are acceptable to the patient. Some patients may not want extensive investigations into their urinary incontinence as they simply want to improve their quality of life by conservative measures. This needs to be respected by the health professional as many treatments used for urinary incontinence have significant unwanted effects and may affect existing medical conditions. NICE (2010) guidelines suggest offering containment products (pads or collecting devices) to achieve social continence until a diagnosis or management plan have been made and that a choice of products should be offered. The guidelines also mention external collecting devices, which include sheath appliances and pubic pressure urinals, before considering indwelling catheterisation. The European Association of Urology (2013) guidelines on incontinence regarding urinary containment as a method of managing urinary continence conclude that containment devices are better than no treatment and penile sheaths offer better containment and higher quality of life than absorbent products in men and are safer than indwelling catheters if no residual urine is present. A randomised controlled trial comparing absorbent products for urinary/faecal incontinence studied the response of 74 men who tested four products designs in randomised order and concluded that the pouch design performed poorly compared to the leaf and insert products and washable pants with a pad inserted were only for men with very light incontinence (Fader et al, 2008).
The male external catheter The male external catheter (MEC), otherwise known as the condom catheter or urinary sheath is a soft, flexible sleeve that fits over the penis and culminates in a short tube that fits onto any standard urinary drainage system (Kyle, 2011). It has been in use for many years but despite £63 million being spent on continence products in the UK each year only 15% of that market is spent on urinary sheaths (Potter, 2007). This suggests that health professionals have been slow to acknowledge that the MEC offers a practical, cost-effective alternative to pads, pants and the indwelling catheter (Potter, 2007). If community nurses lack training and experience in using the MEC they are less likely to recommend it to their patients and may have a negative attitude towards using it. However, if the health professional has the skill, confidence and expertise to show the patient that the MEC is a practical solution to the management of their incontinence, and has enthusiasm and a positive attitude, then most initial difficulties can be overcome (Potter, 2007). The MEC is suitable for men who have moderate to severe urinary incontinence and those who have problems with urgency and frequency and find it difficult to get to the toilet in time (Pomfret, 2006). It is not suitable for men with
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History and examination
British Journal of Nursing, 2014 (Urology Supplement), Vol 23, No 9
British Journal of Nursing. Downloaded from magonlinelibrary.com by 155.198.030.043 on December 3, 2015. For personal use only. No other uses without permission. . All rights reserved.
INCONTINENCE urinary retention (European Association of Urology Nurses (EAUN). 2008) A full continence assessment as described above is essential before considering an MEC as there are potential problems using this device. There are also a variety of products made of different materials so the health professional needs to be knowledgeable about the products and how they are fitted (EAUN, 2008). Modern penile sheaths come in latex and non-latex (silicone) materials, one- or two-piece type, variable penile circumference size and in standard and short lengths. One size certainly does not fit all (Robinson, 2006).
Table 1. User suitability Men for whom sheath is suitable
Men for whom sheath is not suitable
■■ For
■■ Men
stress, urge or continuous incontinence ■■ Temporary need for containment such as travelling, night time, shopping ■■ To control urine flow if spraying occurs when voiding ■■ Men who require versatility and choice when using containment products
Advantages of using a urinary sheath The main advantage of a sheath drainage system is that it is discreet, reliable and can offer physical and psychological benefits. The MEC compares favourably with urinary catheters and pads. A prospective, randomised, unblinded controlled trial involving 75 hospitalised men aged >40 years compared urinary sheaths with indwelling urinary catheters in terms of infection risk and patient satisfaction. Patients without dementia who had an indwelling catheter were five times as likely to develop bacteriuria, symptomatic UTI or to die as those who had a condom catheter (Saint et al, 2006). Compared to pads, the urinary sheath is more hygienic, comfortable, cost effective and is environmentally friendly (Potter, 2007). A randomised, controlled, crossover trial involving 61 adult male outpatients who did not have faecal incontinence was conducted between 2007 and 2009 in France. The participants compared the Conveen Optima urisheath (Coloplast) with their usual absorbent product (AP) for 2 weeks each in respect to quality of life and 69% preferred the urisheath to their usual AP (Fader et al, 2001). Because the MEC directs urine away from the body, the skin has less contact with urine thereby reducing the risk of skin excoriation and infection. The patient may gain confidence, more freedom from embarrassment and can use the sheath for specific occasions such as at night or on a long journey. For patients who also use intermittent self-catheterisation (ISC) there is a special MEC with a removeable tip that allows for catheterisation without disturbing the MEC (EAUN, 2008). For the health professional it can save nursing time as pads or a urinary catheter do not need to be changed.
Disadvantages The main disadvantage of using the MEC is failure of the device to stay in place due to incorrect sizing and fitting
who have a retracted penis or one that retracts when they sit or bend down ■■ Men with broken or excoriated skin ■■ Men with confusion or dementia as they may try to pull the sheath off ■■ Men who have urinary retention ■■ Men who have a history of recurrent UTI ■■ Men with reduced dexterity who do not have a carer to help apply the sheath ■■ Men who have a large glans and a narrow shaft of the penis
(Robinson,2006). Other issues for the nurse to consider are allergic reaction to the materials used to manufacture sheaths, which would include silicone and latex (Woodward, 1997). Allergic reaction, usually to latex, is recognized by the skin becoming inflamed, reddened and oedematous 5-30 minutes after the sheath is applied. If this happens the sheath should be removed immediately and the patient and responsible clinician informed of the material he reacted to so that it is not used again (EAUN, 2008). Other factors make the MEC unsuitable for some men, for instance broken or excoriated skin on the penis, a short or retracted penis, a patient who is confused or does not understand the reason for a sheath being in place and who tries to remove it forceably (Kyle, 2011). Risks associated with incorrect sizing of the MEC include skin necrosis, penile strangulation, pressure sore and urethrocutaneous fistula (EAUN, 2008) Table 1 lists those who are suitable and unsuitable for sheath usage.
Patient assessment Apart from correct measurement and fitting of a MEC success will only be achieved by careful assessment of the patient’s suitability for the product. Will the patient: ■■ Accept wearing the MEC and drainage bag? ■■ Have the ability and dexterity to fit the MEC and drainage bag himself or have a carer or relative to do this for him? ■■ Find the MEC confusing and try to remove it? Also, does the patient: ■■ Have a latex allergy? ■■ Have penile retraction? ■■ Have broken or excoriated skin? ■■ Have a UTI?
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Illustration kindly supplied by Coloplast Ltd
Figure 1. The Convene Optima urinary sheath (Coloplast)
Box 1. Points for nurses to remember when fitting a urinary sheath
a significant residual volume in the bladder? (EAUN,
2008)
■ Measure ■ Check
Tips for users of the urinary sheath ■ Wash
your hands before and after application of the sheath your equipment: sheath, drainage bag, water, soap, wash cloth, towel, scissors if needed ■ Wash penis with soap (not moisturising) and water and do not apply moisturiser or barrier cream as the adhesive will not stick ■ Trim the hair around the penis and its base so hair will not stick to the adhesive. Using a protective cloth or paper towel with a hole cut in it can keep hair out of the way when fitting the sheath ■ Assess the skin of the penis for redness or irritation to determine if the sheath is safe to use ■ Roll out the sheath according to the manufacturer’s instructions before rolling onto the penis ■ Leave 2–3 cm between the tip of the penis and the end of the sheath to avoid kinking or twisting ■ Wait for 15–20 minutess after a bath or shower to allow skin to dry before applying the sheath ■ It helps if the penis is erect but if this is not possible stretching the penis slightly by pulling can help it extend before applying the sheath ■ The sheath should be changed regularly (every 1–3 days) to allow the skin to be washed and dried and to avoid urine infection ■ Gather
(EAUN, 2008)
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Materials and types of sheath There are many different types of MEC in various materials and for the inexperienced person the choice can be overwhelming. The advice of a continence specialist nurse or advisor can be invaluable when choosing the type of product that suits the patient best (Mangera and Chapple, 2010). Research into what type of sheath is best is limited. Two studies have looked into this. The first evaluated six selfadhesive sheaths used by 58 volunteers for 1 week each. The Aquadry Clear Advantage was scored as ‘good’ and the Incare sheath as ‘unacceptable’. The scoring criteria included overall opinion, ease of application and number of detachments (Fader et al, 2001). The second, more recent, study in the UK compared two types of sheath, the new Conveen Optima sheath by Coloplast (Figure 1) and the Clear Advantage sheath (Mentor, US distributed by Coloplast in UK). This was a randomised, prospective, open crossover study involving 53 participants, 67% of whom preferred the Conveen Optima sheath in terms of feeling of security and ease of handling. Nurses who applied the sheath for the patient also found the Conveen Optima easier to apply when wearing gloves (Pemberton et al, 2006). Most modern sheaths are made of latex or silicone but polyvinyl chloride (PVC) and polyurethane (PU) have also been used. Latex is becoming less popular because of latex allergy but silicone is more ‘skin-friendly’ as it is breathable, transparent and rarely causes allergic reactions (EAUN, 2008). Sheaths can be one piece with an integral adhesive or two piece where an adhesive strip is applied to the skin first and then the sheath applied on top (Kyle,2011). The Medical Devices Agency has reported that self-adhesive sheaths are superior to the two-piece system (Medical Devices Agency, 1995).
Measuring and fitting the sheath As mentioned before, correct sizing and fitting of the MEC is essential to avoid the sheath falling off.
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correctly the length and circumference at its widest point patient for allergies and sensitivities, especially latex allergy ■ Select a sheath that is easy to apply to promote confidence in the user ■ Ensure urine bag is correct size and well supported to avoid dragging on the sheath ■ Adjust seating for wheelchair users to allow for better drainage ■ Trim rather than shave pubic hair to prevent it being caught in the sheath adhesive ■ Avoid kinking or twisting of the sheath or drainage bag tubing as this causes pooling of the urine and/or build up of pressure which then prevent drainage and weakens the adhesive ■ Ensure products are available on the Drug Tariff so can be prescribed (Doherty, 2001)
■■ Have
British Journal of Nursing, 2014 (Urology Supplement), Vol 23, No 9
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INCONTINENCE To find the correct size the circumference of the shaft of the penis is measured at its widest point, usually 2 cm from the base of the penis. Most manufacturers provide a measuring device to aid with this. To measure, the patient should be seated on the edge of the bed, couch or chair with legs slightly spread to gain the most natural orientation of the penis and scrotum. Measuring the length of the penis is not usually required as most sheaths will fit most lengths of penis but a length of more than 5 cm is preferred.When the penis is very small or retracted a sheath is not suitable (EAUN, 2008). In the case of the retracted penis there are other products available that can be used but a specialist’s advice would usually be sought for this problem. In the case of a penis that has a smaller diameter than the smallest sheath available a pad may have to be offered.
Conclusion The MEC has been underused as a method of managing male incontinence, often because the nurse or carer lacks the knowledge or expertise to measure and fit it correctly (Robinson, 2006). Nurses need to be aware of the range of products available or either seek advice from an expert or refer the patient to a continence nurse specialist or advisor for further help. A detailed assessment of the patient’s continence problem within the context of a general assessment as well as assessing the patient’s suitability for the product is essential for success. NICE guidelines have now made it clear that management of male lower urinary tract symptoms includes offering a choice of containment products before considering indwelling catheterisation (NICE, 2010). A positive and sensitive attitude in the nurse is important if she or he is to engage the patient in discussing the embarrassing topic of urinary incontinence and work towards a solution that is acceptable and practical for the patient. Successful use of the MEC can make a significant improvement in the patient’s quality of life and help him to manage his urinary incontinence with increased confidence (Williams and Moran, 2006). More research comparing different types of containment products and urinary sheaths is needed to help inform health professionals about product selection as selecting the most BJN appropriate product is not easy. Conflict of interest: none
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Abrams P, Cardozo L, Fall M et al (2002) The standardization of terminology of lower urinary tract function: report for the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 21:167-78 Booth F, Lee L (2005) A guide to selecting and using urinary sheaths. Nursing Times 101(47): 43-6 Busuttil-Leaver R(2009) Male urinary incontinence. Practice Nurse 38(4): 24-8
KEY POINTS n Urinary incontinence in men is a common problem that increases in incidence significantly over the age of 65 n The health professional requires tact, sensitivity and a positive attitude to engage men in discussion on this taboo subject n Detailed assessment of the patient including suitability for a urinary sheath is essential for its successful usage n The urinary sheath provides a practical, cost-effective, discreet method of managing male urinary incontinence but is under-used n Nurses require knowledge and training on the fitting and use of the different products available to avoid failure of the product n The patient’s quality of life can be greatly improved with the judicious use of the urinary sheath Continence Foundation (2000) Making a case for investment in integrated continence services: a source book for continence services. Continence Foundation, London Crestodina LR (2007) Assessment and management of urinary incontinence in the elderly male. Nurse Practitioner 32(9): 26-34 Department of Health (2000) Good Practice in Continence Services. DH, London Doherty W (2001) Urinary sheaths: assessment, prescription and evaluations. Br J Community Nurs 6(2): 80-5 European Association of Urology (2013) Guidelines on urinary incontinence. http://tinyurl.com/kgtkvth (accessed 22 April 2014) European Association of Urology Nurses (2008) Good Practice in Health Care: The male external catheter. http://tinyurl.com/nt9xalw (accessed 9 April 2014) Fader M, Cottenden A, Getliffe K et al (2008) Absorbent products for urinary/ faecal incontinence: a comparative evaluation of key product designs. Health Technol Assess 12(29): 5-7 Fader M, Pettersson L, Dean G, Brooks R, Cottenden AM, Malone-Lee J (2001) Sheaths for urinary incontinence: a randomized crossover trial. BJU Int 88(4): 367-72 Kyle G (2011) The use of urinary sheaths in male incontinence. Br J Nurs 20(6): 338 Mangera A, Chapple C (2010) Investigation and management of urinary incontinence in men. Trends in Urology & Men’s Health 1(1): 27-30. http:// tinyurl.com/qa4lqne (accessed 9 April 2014) Medical Devices Agency (1995) Penile sheaths: a comparative evaluation. Disability Equipment assessment Report – A15. Medical Devices Agency, London National Institute for Health and Clinical Excellence (2010) The management of lower urinary tract symptoms in men. NICE, London. http://tinyurl.com/ lydtxaq (accessed 9 April 2014) Pemberton P, Brooks A, Eriksen CM (2006) A comparative study of two types of urinary sheath. Nurs Times 102(7): 36-41 Pomfret I (2006) Penile sheaths: a guide to selection and fitting. Journal of Community Nursing 20(11): 14-8 Potter J (2007) Male incontinence – could penile sheaths be the answer? Journal of Community Nursing 21(5): 40-2 Robinson J (2006) Continence: sizing and fitting a penile sheath. Br J Community Nurs 11(10): 420-7 Saint A, Kaufman SR, Rogers MA, Baker PD, Ossenkop K, Lipsky BA.(2006) Condom versus indwelling urinary catheters: a randomised trial. J Am Geriatr Soc 54(7): 1055-61 Sand PK, Dmouchowski R (2002) Analysis of The standardisation of the terminology of lower urinary tract dysfunction: report from the standardisation sub-committee on the International Continence Society. Neurourol Urodynam 21: 167-78 [comment on Abrams et al] http://tinyurl.com/q3zg6xt (accessed 29 April 2014) Williams D, Moran S (2006) Use of urinary sheaths in male incontinence. Nurs Times 102(47): 42-5 Woodward S (1997) Complications of allergies to latex urinary catheters. Br J Nurs 6(14): 786-93
Retraction: Regarding Di Giacomo M (2009) Comparison of three peripherally-inserted central catheters: pilot study. Br J Nurs 18(1): 8-16. Since the publication of the article, various flaws have emerged around patient consent, methodology and the title. As a result, this article has been withdrawn from circulation.
British Journal of Nursing, 2014 (Urology Supplement), Vol 23, No 9
S25
British Journal of Nursing. Downloaded from magonlinelibrary.com by 155.198.030.043 on December 3, 2015. For personal use only. No other uses without permission. . All rights reserved.
This article addresses the assessment and management of male incontinence with a specific focus on the use of the male external catheter (MEC) or urinary sheath. Education and expertise when dealing with a man with urinary incontinence, as well as a tactful and sensitive attitude towards this embarrassing problem, are essential for a successful outcome. The urinary sheath is often perceived by nurses and patients as a difficult product to master and is prone to failure owing to incorrect fitting and management. With correct usage it can make a great difference to a patient’s quality of life and avoid problems often associated with urinary catheters and pads such as urinary infection and skin excoriation. Detailed assessment of the patient as well as his suitability for the MEC is essential for a successful outcome. Key words: Male urinary incontinence ■ Male external catheter
■
Urinary sheath
M
ale urinary incontinence remains a taboo subject and because of this many men may be reluctant to seek help with what is often a distressing problem. Urinary incontinence has been defined by the International Continence Society (ICS) as ‘the complaint of any involuntary leakage of urine’ (Sand and Dmouchowski, 2002). In the UK it is estimated that between 2.5 and 4 million adults have continence problems (Continence Foundation, 2000). Of these, one in 33 men living at home aged 15–64 is incontinent of urine and this increases to between one in 14 and one in 10 men aged 65 and over (Department of Health, 2000). Given the increasing ageing population this figure will be a lot higher today and the impact on the individual person’s physical and psychological health cannot be underestimated. Nurses in primary or secondary care are in a prime position to offer assessment and treatment for male incontinence and men may be more willing to admit to having this problem with a nurse who they see regularly as part of ongoing management of chronic health problems than an unfamiliar hospital specialist.
Clare Smart is Urology Nurse Specialist in Benign Urology, Homerton University Hospital, London Accepted for publication: April 2014
S20
The National Institute for Health and Care Excellence (NICE), in its guidelines for the management of lower urinary tract symptoms in men, state that in men with storage symptoms, especially urinary incontinence, a choice of containment products should be offered based on the individual’s circumstances and in consultation with the man (NICE, 2010). This would include external collecting devices, and the urinary sheath is a good example. There is, however, a prevailing negative attitude to using urinary sheaths among nurses as they are not easy to use without appropriate training and knowledge. Once a system has failed because of poor initial assessment, poor fitting, and inappropriate product choice (Booth and Lee, 2005) it is hard to convince a client or health professional that it can be an effective device and that it compares favourably with other methods of urinary containment. This article addresses the assessment and management of male urinary incontinence with a focus on the urinary sheath as a good method of treating incontinence while improving the man’s quality of life. At this point it would be useful to categorise the clinical subtypes of urinary incontinence that can be experienced by men. The following definitions are described by the ICS: ■■ Stress incontinence: involuntary leakage on effort or exertion, sneezing or coughing ■■ Urge incontinence: involuntary leakage of urine accompanied or immediately preceded by urgency (a compelling desire to void that is difficult to defer) ■■ Mixed incontinence: involves components of both stressrelated and urgency-related leakage ■■ Enuresis: any involuntary loss of urine ■■ Nocturnal enuresis: involuntary loss of urine during sleep ■■ Continuous urinary incontinence: continuous leakage. Men may also experience the following conditions, which can lead to incontinence of urine: ■■ Chronic retention of urine: a non-painful bladder, which remains palpable or percussable after the patient has passed urine ■■ Feeling of incomplete emptying: a self-explanatory term for a feeling experienced by the individual after passing urine ■■ Post-micturition dribble: the involuntary loss of urine immediately after the person has finished passing urine, usually after leaving the toilet ■■ Detrusor overactivity (overactive bladder) is a urodynamic observation characterised by involuntary detrusor contractions during the filling phase of the test, which may be spontaneous or provoked (Abrams et al, 2002).
© 2014 MA Healthcare Ltd
Clare Smart
British Journal of Nursing, 2014 (Urology Supplement), Vol 23, No 9
British Journal of Nursing. Downloaded from magonlinelibrary.com by 155.198.030.043 on December 3, 2015. For personal use only. No other uses without permission. . All rights reserved.
Any urinary incontinence should first be investigated as part of a full assessment of the problem. A holistic and sympathetic approach by the health professional is vital to elicit as much information from the patient as possible so that management can be tailored to the individual’s needs. A detailed history and examination will form the basis of investigation into the cause of the incontinence and an assessment of the impact it is having on the individual will guide the type of management that is most suitable. Two useful tools when assessing male lower urinary tract symptoms are the International Prostate Symptom Score (IPSS) and the frequency/volume chart (Busuttil-Leaver, 2009) These help to quantify and categorise the symptoms so that a tentative diagnosis can be made. In addition to these, a detailed medical, surgical, family and medication history should be taken and an evaluation of the social context of the individual and the degree of bother the problem is causing him. Special note should be taken of conditions that often give rise to incontinence such as Parkinson’s disease, cerebrovascular accident, benign prostatic hyperplasia, diabetes, multiple sclerosis, spinal cord injury or disease, urinary tract carcinoma, radiotherapy to pelvic region, surgery to the spine or urological tract (Crestodina, 2007). If the nurse is competent in examining the patient, a focused physical examination should include abdominal examination to detect a palpable bladder (which indicates bladder outflow obstruction), a digital rectal examination of the prostate and rectum (to detect enlarged or diseased prostate, faecal impaction or rectal mass), examination of the genitalia and skin condition (retracted penis, phimosis, excoriation), pelvic floor assessment and a test for leakage of urine on coughing (indicating stress incontinence), and neurological examination. First-line investigations should include urinalysis (to exclude UTI, diabetes and haematuria) and a frequency/ volume chart that has been completed by the patient for at least 3 days at home and at work. If a bladder scanner and a flow rate machine is available, a flow rate and a post-void scan is useful to determine whether or not the patient has an obstructed flow and is retaining urine. Red flag conditions that must be excluded include bladder carcinoma (indicated by haematuria) and chronic retention with overflow (indicated by a palpable bladder) (Mangera and Chapple, 2010).
Differential diagnosis As well as identifying the various types of urinary incontinence already described it is important to recognise transient incontinence which can be correctable. A useful acronym, DIAPPERS can help to identify the cause and stands for: ■■ Delirium ■■ Infection and/or bladder irritants ■■ Atrophic vaginitis/urethritis ■■ Pharmacological causes ■■ Psychological causes ■■ Excessive urine production ■■ Restricted mobility
S22
■■ Stool
impaction. Once a cause has been identified and corrected the patient’s symptoms may improve (Crestodina, 2007).
Management of urinary incontinence The management of incontinence depends on identifying the correct cause of the problem and putting into place treatment and/or lifestyle measures that are acceptable to the patient. Some patients may not want extensive investigations into their urinary incontinence as they simply want to improve their quality of life by conservative measures. This needs to be respected by the health professional as many treatments used for urinary incontinence have significant unwanted effects and may affect existing medical conditions. NICE (2010) guidelines suggest offering containment products (pads or collecting devices) to achieve social continence until a diagnosis or management plan have been made and that a choice of products should be offered. The guidelines also mention external collecting devices, which include sheath appliances and pubic pressure urinals, before considering indwelling catheterisation. The European Association of Urology (2013) guidelines on incontinence regarding urinary containment as a method of managing urinary continence conclude that containment devices are better than no treatment and penile sheaths offer better containment and higher quality of life than absorbent products in men and are safer than indwelling catheters if no residual urine is present. A randomised controlled trial comparing absorbent products for urinary/faecal incontinence studied the response of 74 men who tested four products designs in randomised order and concluded that the pouch design performed poorly compared to the leaf and insert products and washable pants with a pad inserted were only for men with very light incontinence (Fader et al, 2008).
The male external catheter The male external catheter (MEC), otherwise known as the condom catheter or urinary sheath is a soft, flexible sleeve that fits over the penis and culminates in a short tube that fits onto any standard urinary drainage system (Kyle, 2011). It has been in use for many years but despite £63 million being spent on continence products in the UK each year only 15% of that market is spent on urinary sheaths (Potter, 2007). This suggests that health professionals have been slow to acknowledge that the MEC offers a practical, cost-effective alternative to pads, pants and the indwelling catheter (Potter, 2007). If community nurses lack training and experience in using the MEC they are less likely to recommend it to their patients and may have a negative attitude towards using it. However, if the health professional has the skill, confidence and expertise to show the patient that the MEC is a practical solution to the management of their incontinence, and has enthusiasm and a positive attitude, then most initial difficulties can be overcome (Potter, 2007). The MEC is suitable for men who have moderate to severe urinary incontinence and those who have problems with urgency and frequency and find it difficult to get to the toilet in time (Pomfret, 2006). It is not suitable for men with
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History and examination
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INCONTINENCE urinary retention (European Association of Urology Nurses (EAUN). 2008) A full continence assessment as described above is essential before considering an MEC as there are potential problems using this device. There are also a variety of products made of different materials so the health professional needs to be knowledgeable about the products and how they are fitted (EAUN, 2008). Modern penile sheaths come in latex and non-latex (silicone) materials, one- or two-piece type, variable penile circumference size and in standard and short lengths. One size certainly does not fit all (Robinson, 2006).
Table 1. User suitability Men for whom sheath is suitable
Men for whom sheath is not suitable
■■ For
■■ Men
stress, urge or continuous incontinence ■■ Temporary need for containment such as travelling, night time, shopping ■■ To control urine flow if spraying occurs when voiding ■■ Men who require versatility and choice when using containment products
Advantages of using a urinary sheath The main advantage of a sheath drainage system is that it is discreet, reliable and can offer physical and psychological benefits. The MEC compares favourably with urinary catheters and pads. A prospective, randomised, unblinded controlled trial involving 75 hospitalised men aged >40 years compared urinary sheaths with indwelling urinary catheters in terms of infection risk and patient satisfaction. Patients without dementia who had an indwelling catheter were five times as likely to develop bacteriuria, symptomatic UTI or to die as those who had a condom catheter (Saint et al, 2006). Compared to pads, the urinary sheath is more hygienic, comfortable, cost effective and is environmentally friendly (Potter, 2007). A randomised, controlled, crossover trial involving 61 adult male outpatients who did not have faecal incontinence was conducted between 2007 and 2009 in France. The participants compared the Conveen Optima urisheath (Coloplast) with their usual absorbent product (AP) for 2 weeks each in respect to quality of life and 69% preferred the urisheath to their usual AP (Fader et al, 2001). Because the MEC directs urine away from the body, the skin has less contact with urine thereby reducing the risk of skin excoriation and infection. The patient may gain confidence, more freedom from embarrassment and can use the sheath for specific occasions such as at night or on a long journey. For patients who also use intermittent self-catheterisation (ISC) there is a special MEC with a removeable tip that allows for catheterisation without disturbing the MEC (EAUN, 2008). For the health professional it can save nursing time as pads or a urinary catheter do not need to be changed.
Disadvantages The main disadvantage of using the MEC is failure of the device to stay in place due to incorrect sizing and fitting
who have a retracted penis or one that retracts when they sit or bend down ■■ Men with broken or excoriated skin ■■ Men with confusion or dementia as they may try to pull the sheath off ■■ Men who have urinary retention ■■ Men who have a history of recurrent UTI ■■ Men with reduced dexterity who do not have a carer to help apply the sheath ■■ Men who have a large glans and a narrow shaft of the penis
(Robinson,2006). Other issues for the nurse to consider are allergic reaction to the materials used to manufacture sheaths, which would include silicone and latex (Woodward, 1997). Allergic reaction, usually to latex, is recognized by the skin becoming inflamed, reddened and oedematous 5-30 minutes after the sheath is applied. If this happens the sheath should be removed immediately and the patient and responsible clinician informed of the material he reacted to so that it is not used again (EAUN, 2008). Other factors make the MEC unsuitable for some men, for instance broken or excoriated skin on the penis, a short or retracted penis, a patient who is confused or does not understand the reason for a sheath being in place and who tries to remove it forceably (Kyle, 2011). Risks associated with incorrect sizing of the MEC include skin necrosis, penile strangulation, pressure sore and urethrocutaneous fistula (EAUN, 2008) Table 1 lists those who are suitable and unsuitable for sheath usage.
Patient assessment Apart from correct measurement and fitting of a MEC success will only be achieved by careful assessment of the patient’s suitability for the product. Will the patient: ■■ Accept wearing the MEC and drainage bag? ■■ Have the ability and dexterity to fit the MEC and drainage bag himself or have a carer or relative to do this for him? ■■ Find the MEC confusing and try to remove it? Also, does the patient: ■■ Have a latex allergy? ■■ Have penile retraction? ■■ Have broken or excoriated skin? ■■ Have a UTI?
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Illustration kindly supplied by Coloplast Ltd
Figure 1. The Convene Optima urinary sheath (Coloplast)
Box 1. Points for nurses to remember when fitting a urinary sheath
a significant residual volume in the bladder? (EAUN,
2008)
■ Measure ■ Check
Tips for users of the urinary sheath ■ Wash
your hands before and after application of the sheath your equipment: sheath, drainage bag, water, soap, wash cloth, towel, scissors if needed ■ Wash penis with soap (not moisturising) and water and do not apply moisturiser or barrier cream as the adhesive will not stick ■ Trim the hair around the penis and its base so hair will not stick to the adhesive. Using a protective cloth or paper towel with a hole cut in it can keep hair out of the way when fitting the sheath ■ Assess the skin of the penis for redness or irritation to determine if the sheath is safe to use ■ Roll out the sheath according to the manufacturer’s instructions before rolling onto the penis ■ Leave 2–3 cm between the tip of the penis and the end of the sheath to avoid kinking or twisting ■ Wait for 15–20 minutess after a bath or shower to allow skin to dry before applying the sheath ■ It helps if the penis is erect but if this is not possible stretching the penis slightly by pulling can help it extend before applying the sheath ■ The sheath should be changed regularly (every 1–3 days) to allow the skin to be washed and dried and to avoid urine infection ■ Gather
(EAUN, 2008)
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Materials and types of sheath There are many different types of MEC in various materials and for the inexperienced person the choice can be overwhelming. The advice of a continence specialist nurse or advisor can be invaluable when choosing the type of product that suits the patient best (Mangera and Chapple, 2010). Research into what type of sheath is best is limited. Two studies have looked into this. The first evaluated six selfadhesive sheaths used by 58 volunteers for 1 week each. The Aquadry Clear Advantage was scored as ‘good’ and the Incare sheath as ‘unacceptable’. The scoring criteria included overall opinion, ease of application and number of detachments (Fader et al, 2001). The second, more recent, study in the UK compared two types of sheath, the new Conveen Optima sheath by Coloplast (Figure 1) and the Clear Advantage sheath (Mentor, US distributed by Coloplast in UK). This was a randomised, prospective, open crossover study involving 53 participants, 67% of whom preferred the Conveen Optima sheath in terms of feeling of security and ease of handling. Nurses who applied the sheath for the patient also found the Conveen Optima easier to apply when wearing gloves (Pemberton et al, 2006). Most modern sheaths are made of latex or silicone but polyvinyl chloride (PVC) and polyurethane (PU) have also been used. Latex is becoming less popular because of latex allergy but silicone is more ‘skin-friendly’ as it is breathable, transparent and rarely causes allergic reactions (EAUN, 2008). Sheaths can be one piece with an integral adhesive or two piece where an adhesive strip is applied to the skin first and then the sheath applied on top (Kyle,2011). The Medical Devices Agency has reported that self-adhesive sheaths are superior to the two-piece system (Medical Devices Agency, 1995).
Measuring and fitting the sheath As mentioned before, correct sizing and fitting of the MEC is essential to avoid the sheath falling off.
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correctly the length and circumference at its widest point patient for allergies and sensitivities, especially latex allergy ■ Select a sheath that is easy to apply to promote confidence in the user ■ Ensure urine bag is correct size and well supported to avoid dragging on the sheath ■ Adjust seating for wheelchair users to allow for better drainage ■ Trim rather than shave pubic hair to prevent it being caught in the sheath adhesive ■ Avoid kinking or twisting of the sheath or drainage bag tubing as this causes pooling of the urine and/or build up of pressure which then prevent drainage and weakens the adhesive ■ Ensure products are available on the Drug Tariff so can be prescribed (Doherty, 2001)
■■ Have
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INCONTINENCE To find the correct size the circumference of the shaft of the penis is measured at its widest point, usually 2 cm from the base of the penis. Most manufacturers provide a measuring device to aid with this. To measure, the patient should be seated on the edge of the bed, couch or chair with legs slightly spread to gain the most natural orientation of the penis and scrotum. Measuring the length of the penis is not usually required as most sheaths will fit most lengths of penis but a length of more than 5 cm is preferred.When the penis is very small or retracted a sheath is not suitable (EAUN, 2008). In the case of the retracted penis there are other products available that can be used but a specialist’s advice would usually be sought for this problem. In the case of a penis that has a smaller diameter than the smallest sheath available a pad may have to be offered.
Conclusion The MEC has been underused as a method of managing male incontinence, often because the nurse or carer lacks the knowledge or expertise to measure and fit it correctly (Robinson, 2006). Nurses need to be aware of the range of products available or either seek advice from an expert or refer the patient to a continence nurse specialist or advisor for further help. A detailed assessment of the patient’s continence problem within the context of a general assessment as well as assessing the patient’s suitability for the product is essential for success. NICE guidelines have now made it clear that management of male lower urinary tract symptoms includes offering a choice of containment products before considering indwelling catheterisation (NICE, 2010). A positive and sensitive attitude in the nurse is important if she or he is to engage the patient in discussing the embarrassing topic of urinary incontinence and work towards a solution that is acceptable and practical for the patient. Successful use of the MEC can make a significant improvement in the patient’s quality of life and help him to manage his urinary incontinence with increased confidence (Williams and Moran, 2006). More research comparing different types of containment products and urinary sheaths is needed to help inform health professionals about product selection as selecting the most BJN appropriate product is not easy. Conflict of interest: none
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Abrams P, Cardozo L, Fall M et al (2002) The standardization of terminology of lower urinary tract function: report for the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 21:167-78 Booth F, Lee L (2005) A guide to selecting and using urinary sheaths. Nursing Times 101(47): 43-6 Busuttil-Leaver R(2009) Male urinary incontinence. Practice Nurse 38(4): 24-8
KEY POINTS n Urinary incontinence in men is a common problem that increases in incidence significantly over the age of 65 n The health professional requires tact, sensitivity and a positive attitude to engage men in discussion on this taboo subject n Detailed assessment of the patient including suitability for a urinary sheath is essential for its successful usage n The urinary sheath provides a practical, cost-effective, discreet method of managing male urinary incontinence but is under-used n Nurses require knowledge and training on the fitting and use of the different products available to avoid failure of the product n The patient’s quality of life can be greatly improved with the judicious use of the urinary sheath Continence Foundation (2000) Making a case for investment in integrated continence services: a source book for continence services. Continence Foundation, London Crestodina LR (2007) Assessment and management of urinary incontinence in the elderly male. Nurse Practitioner 32(9): 26-34 Department of Health (2000) Good Practice in Continence Services. DH, London Doherty W (2001) Urinary sheaths: assessment, prescription and evaluations. Br J Community Nurs 6(2): 80-5 European Association of Urology (2013) Guidelines on urinary incontinence. http://tinyurl.com/kgtkvth (accessed 22 April 2014) European Association of Urology Nurses (2008) Good Practice in Health Care: The male external catheter. http://tinyurl.com/nt9xalw (accessed 9 April 2014) Fader M, Cottenden A, Getliffe K et al (2008) Absorbent products for urinary/ faecal incontinence: a comparative evaluation of key product designs. Health Technol Assess 12(29): 5-7 Fader M, Pettersson L, Dean G, Brooks R, Cottenden AM, Malone-Lee J (2001) Sheaths for urinary incontinence: a randomized crossover trial. BJU Int 88(4): 367-72 Kyle G (2011) The use of urinary sheaths in male incontinence. Br J Nurs 20(6): 338 Mangera A, Chapple C (2010) Investigation and management of urinary incontinence in men. Trends in Urology & Men’s Health 1(1): 27-30. http:// tinyurl.com/qa4lqne (accessed 9 April 2014) Medical Devices Agency (1995) Penile sheaths: a comparative evaluation. Disability Equipment assessment Report – A15. Medical Devices Agency, London National Institute for Health and Clinical Excellence (2010) The management of lower urinary tract symptoms in men. NICE, London. http://tinyurl.com/ lydtxaq (accessed 9 April 2014) Pemberton P, Brooks A, Eriksen CM (2006) A comparative study of two types of urinary sheath. Nurs Times 102(7): 36-41 Pomfret I (2006) Penile sheaths: a guide to selection and fitting. Journal of Community Nursing 20(11): 14-8 Potter J (2007) Male incontinence – could penile sheaths be the answer? Journal of Community Nursing 21(5): 40-2 Robinson J (2006) Continence: sizing and fitting a penile sheath. Br J Community Nurs 11(10): 420-7 Saint A, Kaufman SR, Rogers MA, Baker PD, Ossenkop K, Lipsky BA.(2006) Condom versus indwelling urinary catheters: a randomised trial. J Am Geriatr Soc 54(7): 1055-61 Sand PK, Dmouchowski R (2002) Analysis of The standardisation of the terminology of lower urinary tract dysfunction: report from the standardisation sub-committee on the International Continence Society. Neurourol Urodynam 21: 167-78 [comment on Abrams et al] http://tinyurl.com/q3zg6xt (accessed 29 April 2014) Williams D, Moran S (2006) Use of urinary sheaths in male incontinence. Nurs Times 102(47): 42-5 Woodward S (1997) Complications of allergies to latex urinary catheters. Br J Nurs 6(14): 786-93
Retraction: Regarding Di Giacomo M (2009) Comparison of three peripherally-inserted central catheters: pilot study. Br J Nurs 18(1): 8-16. Since the publication of the article, various flaws have emerged around patient consent, methodology and the title. As a result, this article has been withdrawn from circulation.
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